The “Chase” Involved in Implementing the Affordable Care Act

Chase scenes—usually involving cars, motorcycles or speedboats—are an adrenaline-producing staple of the Bourne movies, which are some of my favorites. In these scenes, one party, the villain, pursues another party, the hero. The chased tries to evade the chaser by choosing a circuitous, complex route, and often, some sort of distraction or unexpected intervention—such as a train or crowd—prevents the chaser from catching the chased.

Implementing the Affordable Care Act (ACA) can be likened to a long, long chase scene in which significant segments of the public are being asked to chase after the law, i.e., comply with it. But the ACA’s route has certainly been circuitous and complex, and there have been numerous distractions that may ultimately leave some of the populace in the dust of ignorance and nonparticipation.

One can’t blame the public. The ACA is complex, multidimensional in scope, and it features a lengthy, multi-year rollout. A product of two enormous pieces of legislation—the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act—the ACA totalled, before consolidation, over 2,400 pages and contained more than 450 sections.

Last year featured a constitutional challenge that went to the Supreme Court and never-ending talk on Capitol Hill about repeal of the ACA—at last count, the House of Representatives had passed more than three dozen bills repealing the law.

The expansion of Medicaid and the establishment of health insurance exchanges are two of the law’s means of increasing coverage, but they are both areas where many states are not going along with the ACA.

Given the complexity of the law, continued rancor in Washington, D.C. and uneven buy-in by the states, perhaps it’s not surprising that according to the April 2013 Kaiser Health Tracking Poll, 42 percent of Americans are unaware that the ACA is still the law of the land. About half the public says they do not have sufficient information about the health reform law to understand how it will impact their own family. Most distressingly, this share rises among the uninsured and low-income households, the primary intended beneficiaries of the health reform law.

As for distractions, a number of controversies involving the Obama administration emerged in mid-May, two of which in particular could adversely impact the implementation of the ACA. The Internal Revenue Service’s scrutiny of conservative political groups and Secretary of Health and Human Services (HHS) Kathleen Sebelius’ fundraising efforts for Enroll America—a nonprofit organization that seeks to educate Americans about enrolling in healthcare coverage—are both subject to federal investigations. These investigations and their outcomes could hinder HHS’ work in rolling out the healthcare coverage expansion and impact the IRS’s role in enforcing the individual mandate and determining eligibility for health insurance exchange subsidies.

Ultimately, the “X factor” in the success or failure of the ACA’s attempt to expand coverage will be whether the very demographic groups that stand to benefit most from the ACA actually take advantage of various programs established and broadened by the law. Let’s hope that the chase scene of the ACA doesn’t end like most of them do—badly—like the “huge train wreck” that Sen. Max Baucus (D-Mont.) predicted in April because so many of the American people are struggling with the complexity of the law.